Healthcare Provider Details

I. General information

NPI: 1366422008
Provider Name (Legal Business Name): MITCHELL EDWARD BAILEY M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/19/2006
Last Update Date: 10/26/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

30 MARK WEST SPRINGS RD
SANTA ROSA CA
95403-1436
US

IV. Provider business mailing address

9030 W SAHARA AVE # 118
LAS VEGAS NV
89117-5744
US

V. Phone/Fax

Practice location:
  • Phone: 707-328-9673
  • Fax:
Mailing address:
  • Phone: 702-453-3799
  • Fax: 702-453-5741

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208600000X
TaxonomySurgery Physician
License NumberG25349
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: